Provider Demographics
NPI:1144785825
Name:SAMUEL-CLAY, IDA J (LCPC)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:J
Last Name:SAMUEL-CLAY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:J
Other - Last Name:SAMUEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:8342 S PAXTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1852
Mailing Address - Country:US
Mailing Address - Phone:847-722-4074
Mailing Address - Fax:
Practice Address - Street 1:1136 S DELANO CT W STE B201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3734
Practice Address - Country:US
Practice Address - Phone:312-528-3234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011416101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional